Every finding on record at Grand Islander Center

Based on record review and staff interview, the facility failed to ensure that a comprehensive resident assessment was completed for bed rails, including the risk of entrapment, during the bed rail installation for Resident ID #1's bed. Subsequently, the resident was found unresponsive with his/her head and neck caught between the bed rail and the mattress. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health revealed that on [DATE] the resident was found deceased , in a sitting position on the floor, with his/her right elbow resting on the floor and his/her left hand holding the left bed rail. The bed was noted in low position. The nurse's assessment indicated that the resident's skin was warm and dry, without any abrasions, bruising, or signs or symptoms of rigor mortis (the stiffening of the joints and muscles of a dead body). The Medical Examiner (ME) was notified, and the resident's body was released to the ME at 9:30 AM the same morning.A subsequent review of a document titled, Autopsy Report, completed by the ME with an autopsy date of [DATE], indicates that Resident ID #1 was found with his/her head and neck between the bed rail and the mattress, and that a pressure mark was located on the anterior (front) neck extending to the submandibular chin (along the underside of the jawline and upper neck) and from the right angle of the jaw to the left angle of the jaw, an approximately 2-1/2 x 4-inch area of pink to pink-tan to purple ecchymosis (ecchymosis; when blood vessels break under the skin and leak blood into the soft tissue causing bruising). In conclusion, the report indicates that the manner of death is classified as an Accident, with the cause of death listed as Positional Asphyxia (when the body's position prevents a person from breathing adequately).A. Review of the facility's policy titled, Bed Rails states in part, .Centers will only use bed rails as mobility enablers.Review the Bed Safety Evaluation to determine benefits and risks.The Bed Safety Evaluation will be completed upon admission.change in condition in the patient's self-performance of bed mobility (e.g., getting into/out of bed, turning side to side in bed).If a bed rail is used, the Center must ensure proper installation, use, and maintenance of bed rails.PRACTICE STANDARDS:1. Complete the Bed Safety Evaluation to determine the need for bed rails.2. If the Bed Safety Evaluation determines that the patient would benefit from bed rails:2.1 Use the Bed Safety Action Grid to ensure that the bed's dimensions are appropriate for the patient's size and height for the safety and convenience of the patient .2.6 Notify the Maintenance Department to install bed rails or unsecure and inspect fixed bed rails.B. Review of the facility's policy titled, Bed Safety states in part, .Center Maintenance Director, Administrator, and Director of Nursing will conduct an inspection of all bed frames, mattresses, and bed rails, if applicable, as part of a regular maintenance program to identify areas of possible entrapment.Inspections (audits) will occur at a minimum of annually and with any change in bed frame, mattress, or bed rail. The Bed Safety Action Grid and bed safety measuring device will be used to conduct the inspection as they evaluate gaps and potential entrapment risks between headboard, footboard and bed rails.When bed rails and mattresses are used.the Center must ensure that the bed rails, mattress, and bed frame are compatible.If at any time it is determined by Nursing that bed rails are needed for a patient:-Maintenance will ensure correct installation of bed rails, including adherence to manufacturer's recommendations and/or specifications, and-Nursing and Maintenance will complete the Bed Safety Action Grid.C. Review of a facility document titled, Bed Safety Action Grid states in part, Note: This is intended to serve as a visual guide to help identify and minimize any zones of entrapment with bed rail use. This document identifies 7 Descriptions of Entrapment Zones with various pictures of entrapments, including pictures of a head caught in a side rail or between the mattress, head/foot board or bed rail, the category of risk, dimensional criteria and any potential interventions.Record review revealed Resident ID #1 was admitted to the facility in February of 2026 with diagnoses including, but not limited to, dementia, history of falls, lack of coordination, and restlessness. Record review of a written statement, dated [DATE], authored by Licensed Practical Nurse (LPN), Staff A, revealed she was called into Resident ID #1's room for immediate assistance on [DATE]. Upon entering the resident's room, Staff A reported that Resident ID #1 was seated on the floor, legs extended in front of him/her and his/her left arm was flexed along the bed rail. The statement further indicated the resident was observed with his/her head and neck between the mattress and the bed rail, and the lower part of the bed rail was noted under the resident's chin, touching the resident's throat. Additionally, the resident was noted without a palpable pulse or spontaneous respirations. During a surveyor interview on [DATE] at 12:14 PM with Nursing Assistant (NA), Staff B, she revealed that she was assigned to care for Resident ID #1 on the day of the incident, and that she made frequent observations of him/her sleeping during the shift, with the last observation of the resident in bed and asleep at approximately 5:00 AM. Staff B further revealed that at approximately 6:00 AM she entered Resident ID #1's room to find him/her on the floor on the left side of the bed, with his/her back to the bed rail and his/her head and neck was between the mattress and the bed rail. Staff B also revealed that the resident's legs were extended out onto the floor, with his/her buttocks not fully touching the floor, and the resident's left arm was flexed up, holding onto the bed rail. Staff B immediately left the room to get the nurse.During a surveyor interview on [DATE] at 10:38 AM with LPN, Staff C, she revealed that on the morning of [DATE] while completing the medication pass, she was approached by an NA stating that she was needed in Resident ID #1's room, as the NA thought the resident had passed away. Staff C revealed that when she entered the room, she observed the resident located at the left side of his/her bed, with his/her back to the bed rail, holding the bed rail with his/her left hand. The bed was observed in low position with the resident in a sitting position with part of his/her buttocks not fully observed on the floor, and his/her head and neck were caught between the mattress and the bed rail, with his/her chin located in the second hole of the bed rail. The resident was further assessed and was pronounced deceased .During a surveyor interview on [DATE] at 11:45 AM with Registered Nurse, Staff D, she revealed that she was called to Resident ID #1's room by staff following the incident on the morning of [DATE]. She further revealed that management had been contacted regarding the incident and that they were on route to the facility. Staff D was asked to assess the resident for any visible injuries, and no injuries were noted. The ME was called and responded to the facility that morning. During a surveyor interview on [DATE] at 12:01 PM with, LPN, Staff E, she revealed that she completed the initial Bed Safety Evaluation for Resident ID #1 upon his/her admission to the facility and concluded that the resident's body strength was not adequate without the use of bed rails; the resident needed bed rails for bed mobility. She further indicated that the assessment should have triggered the Bed Safety Evaluation Follow-Up, which is completed when the bed rails are installed on the bed, as this assessment also includes assessing the zones of entrapment. Staff E revealed that she then placed a work order for the maintenance department to place bed rails on Resident ID #1's bed on [DATE]. Additionally, Staff E was unable to provide evidence of a completed Bed Safety Evaluation Follow-Up assessment for the resident.Record review of a nursing progress note dated [DATE], authored by Staff E indicated that the resident's representative requested that s/he have side rails placed to use as an enabler for bed mobility. The risks and benefits were addressed with the resident's representative, and a consent for side rails was completed.Record review of a written statement dated [DATE] and authored by the former Maintenance Assistant, Staff F, revealed that he received the notification that bed rails were needed for Resident ID #1's bed so he retrieved two bed rails from his office to install. After arriving to Resident ID #1's room, Staff F stated that he removed the resident's mattress from the bed frame and placed the two bed rails on the resident's bed, making sure they were installed tightly. Further review of the statement failed to reveal evidence that Staff F completed the required risk of entrapment assessment utilizing the Bed Safety Action Grid, once the bed rails were installed. Further record review failed to reveal evidence that the Follow-Up Bed Safety Evaluation was completed, to ensure that the resident was properly assessed for the risk of entrapment when the bed rails were applied. During a surveyor interview on [DATE] at 10:55 AM with the Regional Clinical Director, he acknowledged that the Bed Safety Evaluation, including the risk of entrapment, was not completed for Resident ID #1 when the bed rails were installed by the Maintenance Assistant. Additionally, he acknowledged that the Maintenance Assistant's statement did not indicate that he completed the risk of entrapment assessment per the facility's policy. The facility failed to ensure a comprehensive assessment was completed for Resident ID #1, who had a history of falls and was assessed to need bed rails for bed mobility. Subsequently, Resident ID #1 was found deceased , with his/her head and neck caught between the bed rail and the mattress. Upon further assessment of the ME's autopsy results, the ME concluded that the resident's cause of death was positional asphyxiation. This failure placed Resident ID #1 at risk for more than minimal harm, serious injury, or death.Cross reference F 609

Based on record review and staff interview, the facility failed to accurately report to the State Agency, an incident including the full details and circumstances surrounding the death of a resident, who was observed by staff deceased , with his/her head and neck between the mattress and the bed rail. Additionally, the former Administrator who also observed the resident in this manner, omitted these details when reporting the incident involving Resident ID #1. Findings are as follows:Record review of a facility reported incident initially submitted to the Rhode Island Department of Health (RIDOH) by the former facility Administrator on [DATE], revealed that on the morning of [DATE] at approximately 6:40 AM Resident ID #1 was found deceased , in a sitting position on the floor. Emergency Medical Services was contacted, as well as the Medical Director and the Medical Examiner's (ME) Office, due to the unexpected incident.Record review of the 5-day facility investigation report submitted to the RIDOH by the former facility Administrator on [DATE], revealed that Resident ID #1 was observed sitting on the floor with both brown socks on, and that his/her right elbow was resting on the floor and his/her left hand was holding the left bed rail. The bed was in low position, and the resident's skin was observed to be warm and dry without abrasions, bruising, or signs and symptoms of rigor mortis (the stiffening of the joints and muscles of a dead body). The family, Medical Director, and the ME were notified, and the resident's body was released to the ME at 9:30 AM pending a final diagnosis. Record review of a separate binder containing several documents provided by the facility during the survey, revealed a written statement authored by Licensed Practical Nurse, Staff A, who responded to the resident's room after a Nursing Assistant (NA) called for her assistance on [DATE]. The written statement indicated that upon entering Resident ID #1's room, the resident was observed seated on the floor, with his/her legs extended in front of him/her and his/her left arm was flexed along the bed rail. The statement further indicated that the resident's head and neck were between the mattress and the bed rail, and the lower part of the bed rail was noted under the resident's chin, touching the resident's throat. Additionally, the resident was noted without a palpable pulse or spontaneous respirations. During a review of Resident ID #1's electronic medical record by the surveyor prior to reviewing the separate binder, failed to indicate that the resident's head and neck were caught between the mattress and the bed rail or that his/her chin and throat were located within the rail of the bed. Additionally, a subsequent review of a document titled, Autopsy Report, completed by the ME with an autopsy date of [DATE], indicates that Resident ID #1 was found with his/her head and neck between the bed rail and the mattress, and that a pressure mark was located on the anterior (front) neck extending to the submandibular chin (along the underside of the jawline and upper neck) and from the right angle of the jaw to the left angle of the jaw, an approximately 2-1/2 x 4-inch area of pink to pink-tan to purple ecchymosis (ecchymosis; when blood vessels break under the skin and leak blood into the soft tissue causing bruising). In conclusion, the report indicates that the manner of death is classified as an Accident, with the cause of death listed as Positional Asphyxia (when the body's position prevents a person from breathing adequately).During a surveyor interview on [DATE] at 11:45 AM with Registered Nurse, Staff D, she indicated that she was called to Resident ID #1's room by staff following the incident on the morning of [DATE]. She further revealed that management had been contacted by staff regarding the incident, and that the former Administrator and the current Director of Nursing Services were on route to the facility and that that the Administrator responded to the resident's room to observe the resident that morning, prior to the ME responding and leaving with the resident. Record review of the former Administrator's statement subsequently submitted to the Regional Clinical Director via email on [DATE] at 2:18 PM states in part, I was contacted.that a resident had expired following a fall.The nurse stated that the resident's head was positioned at the side of the bed, with her chin resting on the side rail.Upon arrival.I observed the resident and confirmed that [Resident ID #1's] positioning was consistent with the description provided by the nurse. The former Administrator's statement failed to indicate the details surrounding the resident's position when s/he was found deceased . She failed to reveal that his/her head and neck were between the mattress and the bed rail, when reporting the incident to the State Agency. During a surveyor interview on [DATE] at 10:55 AM with the Regional Clinical Director, he was unable to provide evidence that the former Administrator reported the complete circumstances surrounding the resident's fall from his/her bed, including that the resident's head and neck were found between the mattress and the bed rail.Cross reference F 700

Based on record review and staff interview, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident, relative to the former Administrator failing to ensure that the facility's policy was implemented and that inspections were conducted to identify areas of possible entrapment with the installation of bed rails, Resident ID #1. Findings are as follows:Record review of a facility reported incident initially submitted to the Rhode Island Department of Health (RIDOH) by the former facility Administrator on [DATE], revealed that on the morning of [DATE] at approximately 6:40 AM Resident ID #1 was found deceased , in a sitting position on the floor holding the left bed rail. Emergency Medical Services was contacted, as well as the Medical Director and the Medical Examiner's (ME) Office, due to the unexpected incident. A. Review of the facility's policy titled, Bed Rails states in part, .Centers will only use bed rails as mobility enablers.Review the Bed Safety Evaluation to determine benefits and risks.If a bed rail is used, the Center must ensure proper installation, use, and maintenance of bed rails.PRACTICE STANDARDS:1. Complete the Bed Safety Evaluation to determine the need for bed rails.2. If the Bed Safety Evaluation determines that the patient would benefit from bed rails:2.1 Use the Bed Safety Action Grid to ensure that the bed's dimensions are appropriate for the patient's size and height for the safety and convenience of the patient .2.6 Notify the Maintenance Department to install bed rails or unsecure and inspect fixed bed rails.B. Review of the facility's policy titled, Bed Safety states in part, .Center Maintenance Director, Administrator, and Director of Nursing will conduct an inspection of all bed frames, mattresses, and bed rails, if applicable, as part of a regular maintenance program to identify areas of possible entrapment.Inspections (audits) will occur at a minimum of annually and with any change in bed frame, mattress, or bed rail. The Bed Safety Action Grid and bed safety measuring device will be used to conduct the inspection as they evaluate gaps and potential entrapment risks between headboard, footboard and bed rails.When bed rails and mattresses are used.the Center must ensure that the bed rails, mattress, and bed frame are compatible.Record review of a separate binder containing several documents provided by the facility during the survey, revealed a written statement authored by Licensed Practical Nurse, Staff A, who responded to the resident's room after a Nursing Assistant (NA) called for her assistance on [DATE]. The written statement indicated that upon entering Resident ID #1's room, the resident was observed seated on the floor, with his/her legs extended in front of him/her and his/her left arm was flexed along the bed rail. The statement further indicated that the resident's head and neck were between the mattress and the bed rail, and the lower part of the bed rail was noted under the resident's chin, touching the resident's throat. Additionally, the resident was noted without a palpable pulse or spontaneous respirations. Additionally, a subsequent review of a document titled, Autopsy Report, completed by the ME, with an autopsy date of [DATE] indicates that Resident ID #1 was found with his/her head and neck between the bed rail and the mattress, and that a pressure mark was located on the anterior (front) neck extending to the submandibular chin (along the underside of the jawline and upper neck) and from the right angle of the jaw to the left angle of the jaw, an approximately 2-1/2 x 4-inch area of pink to pink-tan to purple ecchymosis (ecchymosis; when blood vessels break under the skin and leak blood into the soft tissue causing bruising). In conclusion, the report indicates that the manner of death is classified as an Accident, with the cause of death listed as Positional Asphyxia (when the body's position prevents a person from breathing adequately).The former Administrator failed to ensure that the facility's policy was implemented and that inspections were conducted of all bed frames, mattresses, and bed rails, as part of their regular maintenance program to identify areas of possible entrapment. Additionally, the Administrator failed to ensure that inspections occurred at a minimum of annually and with any change in bed frame, mattress, or bed rail utilizing the Bed Safety Action Grid and bed safety measuring device to evaluate gaps and potential entrapment risks between the headboard, footboard, and bed rails. Resident ID #1 who was admitted to the facility, assessed for and required bed rails for bed mobility had bed rails installed, however no further assessment was completed for entrapment once the bed rails were installed. Subsequently on the following morning, the resident was found deceased , with his/her head and neck between the bed rail and the mattress.During a surveyor interview on [DATE] at 10:55 AM with the Regional Clinical Director, he was unable to provide evidence that the former Administrator ensured that inspections were conducted to identify areas of possible entrapment with the installation of bed rails.

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive care, consistent with professional standards of practice, relative to 1 of 1 resident reviewed for abnormal blood work, Resident ID #1.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314, states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.Record review revealed the resident was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, hyperosmolality and hypernatremia (conditions related to abnormally high levels of sodium in the blood stream).Review of a progress note dated 10/25/2025 at 8:20 PM revealed that Resident ID #1's bloodwork was reviewed with the provider who gave several new orders that included, repeat a basic metabolic panel (BMP, a blood test that measures substances in your blood to assess overall health) on Monday (10/27/2025).Review of a physician's order dated 10/25/2025 revealed that the resident was to have his/her repeat BMP drawn on 10/27/2025.Record review failed to reveal evidence that the resident had the repeat BMP on 10/27/2025, as ordered.During a surveyor interview on 10/29/2025 at 12:29 PM with the Director of Nursing Services, in the presence of the Administrator, she revealed that she would expect that the BMP to have been completed on 10/27/2025, as ordered.

Based on record review and staff interview, it has been determined that the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident reviewed for behaviors, resulting in a transfer to an acute care hospital, Resident ID #1.Findings are as follows:Review of a facility reported incident submitted to the Rhode Island Department of Health on 10/28/2025 revealed, Resident ID #1 was displaying disruptive and self-injurious behaviors, and the provider was notified, and ordered to send the resident to the hospital for an evaluation. Additionally, while awaiting transfer, the resident was found in his/her room with a plastic bag over his/her head. Further, staff immediately removed the bag and then s/he was placed on a 1:1 supervision until s/he was transferred to the hospital.Review of a facility job description for a Social Services position revised 11/17/2020 states in part, Advocacy.Works with patients/residents, families, and significant others to provide support and information for taking a more proactive role in self-advocacy to improve the quality of life/care for individual patients/residents.Record review revealed the resident was admitted to the facility in April of 2024 with a diagnosis including, but not limited to, psychotic disorder with hallucinations due to a known physiological condition.Review of a progress note dated 10/28/2025 at 10:57 AM revealed, the resident was becoming extremely behavioral, and the provider was contacted. Additionally, the resident was found in his/her room with a plastic bag over his/her head. Further, the bag was removed, s/he was placed on 1:1 supervision, and transported to the hospital for a psychiatric evaluation.Review of the facility acute care transfer form document that was sent with the resident to the hospital revealed that s/he was recently issued a 30-day notice by the facility related to billing.Review of a document titled, emergency room VISIT NOTES dated 10/28/2025, states in part, .Per RN [Registered Nurse] at NF [Nursing Facility] '[S/he] needs a lot of help and won't let us help [him/her].[S/he] got a thirty day notice the other day for not paying, and I know that upset [him/her].'During a surveyor interview on 10/29/2025 at 12:10 PM with RN, Staff A, she revealed that she was unsure if Social Services had visited with the resident following the issuance of his/her 30-day notice and would have expected them to. She further revealed that the 30-day notice could have prompted his/her increased behaviors that resulted in a hospital transfer on 10/28/2025.During a surveyor interview on 10/29/2025 at 12:19 PM, with the Social Worker, she revealed that the resident and his/her family members were at the facility on Monday, 10/27/2025, the day before the incident occurred, and were having discussions regarding the 30-day notice. She further revealed that she was aware that the resident and his/her family were present at the facility and indicated that she attempted four or five times to visit with the resident, however, did not end up speaking with the resident or his/her family.Record review failed to reveal evidence that the Social Worker spoke to, or attempted to speak to, the resident and/or his/her representative(s) following the issuance of a 30-day notice, until after the surveyor initially inquired.During surveyor interviews on 10/29/2025 at 9:12 AM and 12:26 PM, with the Administrator, she revealed that the facility issued Resident ID #1 a 30-day notice for non-payment on Friday, 10/24/2025. Additionally, she was unable to provide evidence that the facility provided medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident ID #1 after s/he was issued a 30-day notice by the facility.During a surveyor interview on 10/29/2025 at 12:45 PM with the resident's representative, they revealed that they were unaware that the Social Worker was available to speak with on 10/27/2025, nor did the Social Worker make any attempt to speak with them while they were at the facility. They further revealed that they had been requesting to speak with a case manager but the facility offered nothing.

Based on record review and staff interview, the facility failed to ensure a resident receives adequate assistance during transfers to prevent accidents for 1 of 1 resident reviewed, resulting in a left spiral distal tibia fracture (a break in the lower shinbone near the ankle, fracture line that spirals around the bone, often caused by a twisting force) and a [NAME] bilateral distal fibula fracture (a break in the fibula bone of both ankles), Resident ID #2. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 9/3/2025 reveals that Resident ID #2 complained of pain in his/her left lower extremity and groin. Nursing assessed the resident and found his/her left lower extremity to be swollen and painful. The resident was ordered to be sent to the emergency room to rule out a deep vein thrombosis (DVT - a blood clot in a vein located deep within the body, commonly found in the leg). The facility was informed that the resident had sustained a left tibia (shin bone) and fibula (smaller of the two lower leg bones between the knee and the ankle) fracture, and would be admitted . The resident had not had a fall, and the cause of the fractures were unknown.Record review revealed the resident was admitted to the facility in November of 2022 with a diagnosis including, but not limited to, Parkinson's disease.Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15, indicating the resident is cognitively intact.Record review of the resident's Lift Transfer Evaluation dated 8/11/2025, revealed the resident required the assist of two people for transfers, with the use of a gait belt (a safety device used to help someone move) and device.Record review of the resident's care plan dated 8/22/2025 revealed that the resident required the assist of two people for transfers, with the use of a gait belt.Record review of a progress note dated 9/2/2025 at 10:35 AM revealed that while assessing the resident and performing a dressing change, the resident complained of pain to his/her left leg and significant edema (swelling caused by excess fluid trapped in your body's tissues) was noted. The resident was assessed by a Nurse Practitioner, and she ordered the resident to be sent to the emergency department to rule out a DVT.Record review of a hospital document dated 9/2/2025, revealed the resident presented to the hospital with a left spiral distal tibia fracture and a [NAME] bilateral distal fibula fracture. Further review revealed the injury was non operable, the resident was to be non-weight bearing and was casted on his/her left lower extremity up to his/her knee.During a surveyor interview on 11/24/2025 at 1:05 PM with the resident, s/he revealed that during a stand pivot transfer (SPT) with Nursing Assistant (NA), Staff A , he attempted to transfer the resident independently, however during the transfer, while the resident was turning to sit, s/he stated that s/he heard a pop and fell backwards and s/he was unable to get back up to complete the transfer. The resident indicated at that time Staff A went to get another NA, Staff B, to assist getting the resident into bed.During a surveyor interview on 11/24/2025 at 1:55 PM with the Director of Rehabilitation, she indicated that the type of fracture sustained by Resident ID #2 would most likely occur during a SPT, when the person does not advance their leg and twists to sit.During a surveyor interview on 11/24/2025 at approximately 3:20 PM with NA, Staff B, he revealed that prior to the resident being non weight bearing and, in a cast, he would transfer the resident independently using a SPT technique. Additionally, he revealed that the resident had always been a SPT and required the assistance of one person. He further revealed that he believed that the resident sustained the fracture during a transfer as the resident would often not lift his/her foot when turning which resulted in the twisting of his/her leg during transitions. Additionally, he revealed that the resident had always been a SPT and required the assistance of one person.During a surveyor phone interview on 11/25/2025 at 12:15 PM with NA, Staff A, he recalled an incident prior to the resident's hospitalization, that when transferring the resident in the bathroom, the resident pulled up to the bar from his/her wheelchair, he assisted the resident to raise from the wheelchair, and s/he suddenly went backwards into the wheelchair. At the time the resident stated the s/he was unable to get out of the wheelchair. Staff A stated he then repositioned the resident in the wheelchair and proceeded to get assistance from Staff B to put the resident in bed to perform care.Record review of documents titled, Daily Staffing Sheets revealed the assignments for Resident ID #2's unit:NA, Staff A, worked the following shifts: 8/31/2025- 5:00 PM -11:00 PM and 11:00 PM -7:00 AM 9/1/2025 -3:00 PM- 11-00 PM and 11:00 PM - 7:00 AM 9/2/2025- 11:00 PM - 7:00 AMNA, Staff B, worked the following shifts: 8/31/2025 - 7:00 AM-3:00 PM and 3:00 PM - 11:00 PM 9/1/2025 - 7:00 AM-3:00 PM and 3:00 PM - 11:00 PM 9/2/2025 - 7:00 AM-3:00 PM and 3:00 PM - 11:00 PMDuring a surveyor interview on 11/25/2025 at 3:39 PM with the Administrator, in the presence of the Director of Nursing Services, she was unable to provide evidence that the resident was provided with two members during a transfer as indicated on his/her care plan and Lift Transfer Evaluation.It was determined that Resident ID #2 sustained significant, non-operable fractures to the left tibia and fibula consistent with improper or inadequate assistance during a SPT. Although the resident's care plan and transfer evaluation clearly required the assistance of two staff members with a gait belt, multiple interviews revealed that staff routinely transferred the resident independently. Both the resident and staff reported incidents in which the resident twisted or fell backward during transfers, and the Director of Rehabilitation confirmed that the type of fractures sustained are consistent with twisting during a SPT when the leg is not properly advanced.Staff schedules confirm that the staff members involved were on duty during the relevant time frame. Despite this, the facility was unable to produce evidence that appropriate assistance was provided in accordance with the resident's assessed transfer needs. As a result, the investigation concludes that the facility did not ensure that the resident received adequate supervision and assistance to prevent accidents, which likely contributed to the injuries sustained.During a surveyor interview with the Director of Nursing on 11/21/2025 at approximately 9:50 AM, she provided evidence of the interventions which were initiated after a citation for a similar incident was discovered during a complaint investigation at the facility on 10/23/2025 through 10/24/2025. The following interventions were initiated and or completed with a substantial date of compliance of 11/20/2025:a. A facility wide review was conducted on 11/20/2025 to identify residents who may be at risk related to supervision and use of assistive devices. All residents were verified to have an accurate transfer status and appropriate assistive devices.b. Staff education was provided to direct care staff regarding safe resident handling and fall prevention, which was completed on 11/20/2025.c. The Rehabilitation Department initiated education to their staff regarding timely communication and documentation of resident transfer updates, education was initiated in 11/1/2025. Compliance data will be submitted to Quality Assurance and Performance Improvement (QAPI). Education on the care plan process and updating assessments, with any changes was initiated on 11/6/2025.d. Random gait belt audits are to be conducted for 4 weeks, followed monthly for 3 months, to ensure proper use of assistive devices during transfers. Findings will be submitted to QAPI.e. Weekly fall audits were initiated on 10/14/2025 and will continue to be conducted for 4 weeks, followed monthly for 3 months, to ensure proper use of assistive devices during transfers. Findings will be reviewed during QAPI meetings.f. Weekly audit of Quality Measure rounds for any residents with a change in condition for 4 weeks, followed monthly for 2 months. Findings will be discussed during QAPI meetings.

Based on record review and staff interview, the facility failed to ensure that a resident receives care consistent with professional standards of practice relative to physician's orders for 1 of 2 residents reviewed for wound care, Resident ID #1Findings are as follows:Review of a facility reported incident submitted to the Rhode Island of Health on 10/1/2025 states in part, that the resident's daughter had made an allegation of neglect against the facility.According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe that the orders are in error or wound harm the clients.Record review revealed the resident was admitted to the facility in August of 2022, with a diagnosis including, but not limited to, basal cell carcinoma (skin cancer).Record review of a progress note dated 8/21/2025 revealed, the resident had a MOHS surgery (a surgical procedure to remove skin cancer) on 8/19/2025.Record review of a Continuity of Care Consultation and Referral Form signed and dated 9/26/2025 by the dermatologist, states in part, .white vinegar and water, 50:50-soaks daily to left temple x 2 weeks. Manuka Honey (a medical honey used for wound healing) twice a day to raw areas on face/neck.do twice a day until healed.Record review of the Treatment Administration Records (TAR) from September 2025 through November 2025 failed to reveal evidence that the above-mentioned physician's orders were implemented. Additional record review failed to reveal evidence the physician at the facility had declined the dermatologist's orders dated 9/26/2025. During a surveyor interview on 11/25/2025 at 12:40 PM with the Administrator, she was unable to provide evidence that the above-mentioned physician's orders had been followed. Additionally, she indicated that she would expect the staff to verify the dermatologist order with the physician at the facility and was unable to provide evidence the order was verified or declined by the physician at the facility.

Based on record review and staff interview, it has been determined that the facility failed to ensure each resident receives adequate supervision to prevent accidents relative to 1 of 3 residents reviewed for falls with injury, Resident ID #1.Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/21/2025 indicates that Resident ID #1 was coming out of his/her room with Nursing Assistant (NA; Staff A) when the resident let go of his/her walker and fell backwards, landing on his/her buttocks. When the resident was getting up s/he grabbed the door, which swung open and hit the resident on the head. The resident then went to get up and the staff heard a pop in his/her hip area. The resident complained of hip pain and was transferred to an acute care hospital where s/he was diagnosed with a hip fracture.Record review revealed the resident was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, fracture of the left hip, Alzheimer's disease, repeated falls, and abnormalities of gait and mobility.Record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief Interview for Mental Status score of 4 out of 15, indicating severe cognitive impairment. Additional review revealed s/he requires supervision and/or touch assistance by staff when ambulating.Record review of a Physical Therapy PT Discharge Summary dated 5/27/2025 through 9/5/2025, states in part, .Patient Progress.[S/he] currently requires S/SBA [supervision/stand-by assist, indicating staff is to be nearby to ensure the patient's safety] with RW [rolling walker] to ambulate 225 ft [feet]. Pt [patient] requires staff assist x1 with RW and S/SBA for ambulation.Review of a progress note dated 10/14/2025 states in part, CNA [nursing assistant] said she was walking resident out to dining room. The resident let go of walker and fell backwards. [S/he] did not hit [his/her] head.Upon assessment resident expressed extreme pain, when [s/he] moved a pop was heard possibly [emanating] from the l [left] hip area. Np [Nurse Practitioner, name redacted] was called. It was decided to send resident to.hospital via 911.Additional review of the resident's records revealed the resident was admitted to the hospital on [DATE] with a left femoral neck fracture and underwent surgery for repair.During a surveyor interview on 10/23/2025 at 1:40 PM with NA, Staff A, she revealed that she has cared for Resident ID #1 several times and knows him/her well. She indicated that on 10/14/2025, she had just finished the resident's care prior to the lunch meal and walked out of the resident's room ahead of him/her while s/he was ambulating with a walker behind her. She indicated that when she turned around, the resident had let go of the walker and fell backwards onto his/her bottom. Additionally, she indicated that by the time she turned around, the resident was too far down to assist. She revealed that immediately following the fall, another NA came to assist her to keep the resident in place until the nurse came over to conduct an assessment of the resident. During that time, the resident tried to get up, and both she and the other NA heard a sound that came from the resident's hip. The resident stated that s/he was in pain. Further, Staff A indicated that she was told that the resident was independent with walking and did not need assistance from staff.During a surveyor interview with the Director of Rehabilitation on 10/23/2025 at 2:43 PM, she revealed that at the time the resident was discharged from physical therapy on 9/5/2025, s/he required supervision/stand-by assistance for ambulation with a rolling walker and was not independent with ambulation. She indicated she would expect staff to stand next to or behind the resident within arm's length ready to assist if needed.During a surveyor interview with the Director of Nursing on 10/24/2025 at 2:34 PM, she revealed that she would expect staff to follow physical therapy recommendations to provide supervision and stand-by assistance as reflected in the resident's MDS and care plan. Additionally, she was unable to provide evidence that the resident was provided with adequate supervision to prevent accidents.

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident reviewed who had actual fall with injury, Resident ID #1, and for 1 of 6 residents reviewed for transfers, Resident ID #2.Findings are as follows:1. Record review revealed Resident ID #1 was re-admitted to the facility in July of 2025 with diagnoses including, but not limited to, displaced intertrochanteric fracture of left femur (a broken hip).Record review of a progress note dated 7/20/2025 revealed, Resident ID #1 had been found lying on the floor at 8:00 AM in the doorway of his/her room. The resident indicated that s/he had pain to his/her left hip with swelling noted. The resident was emergently sent out to the hospital for further evaluation.Further review of his/her progress notes revealed that the resident was admitted to the hospital with a hip fracture and would require surgery to repair prior to returning to the facility.Review of a care plan focus area for falls dated 9/12/2023, failed to reveal evidence that the resident sustained an actual fall with injury on 7/20/2025.During a surveyor interview on 8/20/2025 at 3:48 PM, with the Director of Nursing Services, she was unable to provide evidence that a comprehensive person-centered care plan was developed and implemented to accurately address the resident's fall with injury.2. Record review revealed Resident ID #2 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, unspecified fracture of left patella (kneecap) pain in left hip, and dementia.Review of a care plan initiated on 2/11/2025, revealed the resident requires total assistance of 2 staff persons for transfers, using a mechanical lift (a mechanical device that is used to transfer individuals who cannot bear weight or actively assist with transfers themselves).Additional review of the resident's care plan revealed a focused area for Special Instruction which states in part Slide Board (a specialized board that acts as a bridge to allow individuals to move from one seated surface to another seated surface) for transfers.4/17/25.Review of a document titled CAA Triggers Summary dated 7/29/2025 revealed in part, that the resident was dependent (the resident does not actively assist in the transfers) for all transfers. During a surveyor interview on 8/20/2025 at 3:48 PM, with the Director of Nursing Services, she acknowledged that two different devices used for resident transfers were identified on the care plan. She was also unable to provide evidence that a comprehensive person-centered care plan was developed and implemented to accurately indicate a specific transfer device for Resident ID #2.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care related to abuse and neglect training for 1 of 3 Nursing Assistants (NA) reviewed, Staff A. Findings are as follows:Review of a facility reported incident of alleged staff to resident abuse that was reported to the Rhode Island Department of Health on 7/28/2025, revealed on 7/27/2025 Resident ID #5 alleged that s/he was abused by NA, Staff A.Record review of a facility policy titled Abuse Prohibition Policy last revised 10/24/2022 states in part, .Training and reporting obligations will be provided to all employees -through orientation, Code of Conduct training, and a minimum of annually-and will include. the Abuse Prohibition policy.Record review revealed Resident ID #5 was admitted to the facility in May of 2025 with diagnoses including, but not limited to, multiple sclerosis (a chronic, often disabling disease that affects the brain and spinal cord) and rheumatoid arthritis (a chronic autoimmune disease that primarily causes inflammation of the joints, leading to pain, swelling, stiffness, and potential joint damage).Record review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident is cognitively intact.Record review revealed Staff A was hired by the facility on 6/23/2025. Record review failed to reveal evidence that Staff A had completed education relative to Abuse Prohibition upon hire, as required. During a surveyor interview on 8/20/2025 at 3:48 PM with the Director of Nursing Services, in the presence of the Administrator, she was unable to provide evidence that Staff A had completed training in abuse. Additionally, she indicated that she would have expected Staff A to have received additional Abuse Prohibition training following the allegations made by Resident ID #5 on 7/27/2025.

Based on record review, staff and resident interview, it has been determined that the facility failed to ensure that a resident's comprehensive person-centered care plan was implemented relative to weekly skin assessments for 3 of 7 residents reviewed, Resident ID #s 29, 32 and 172. Findings are as follows: 1. Record review for Resident ID #29 revealed s/he was re-admitted to the facility in February of 2025 with a diagnosis including, but not limited to, stroke. Record review revealed a care plan dated 2/27/2024 to conduct a comprehensive skin inspection weekly. Record review of the resident's weekly skin inspection documentation failed to reveal evidence that a weekly skin inspection was completed since 5/2/2025, indicating that the skin assessment was not completed on 5/9/2025. During a surveyor interview on 5/14/2025 at 3:06 PM with the Assistant Director of Nursing (ADON), she was unable to provide evidence that the resident's skin assessment was completed weekly, per the plan of care. 2. Record review for Resident ID #32 revealed s/he was admitted to the facility in May of 2024 with a diagnosis including, but not limited to, stroke. Record review revealed a care plan dated 5/28/2024 to conduct a comprehensive skin inspection weekly. Record review of the resident's weekly skin inspection documentation failed to reveal evidence that a weekly skin assessment was completed since 4/17/2025, indicating that the skin assessments were not completed on 4/24, 5/1, and 5/8/2025. During a surveyor interview on 5/14/2025 at 1:52 PM with Registered Nurse, Staff A, she was unable to provide evidence that the resident's skin assessments were completed weekly, per the plan of care. 3. Record review for Resident ID #172 revealed s/he was admitted to the facility in May of 2025 with a diagnosis including, but not limited to, dementia. Record review revealed a care plan dated 5/5/2024 for weekly skin checks by a licensed nurse. Record review of the resident's weekly skin assessment documentation failed to reveal evidence that a weekly skin assessment was completed since 5/3/2025, indicating that the skin assessment was not completed on 5/10/2025. During a surveyor interview on 5/14/2025 at 2:00 PM with the ADON, she was unable to provide evidence that the resident's skin assessment was completed weekly, per the plan of care.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to Enhanced Barrier Precautions (EBP; involves using a gown and gloves during high-contact resident care activities) for 2 of 2 residents reviewed with wounds, Resident ID #s 34 and 47, and for 1 of 1 resident reviewed with a urinary catheter, Resident ID #88. Findings are as follows: Review of a facility policy titled, .Enhanced Barrier Precautions (EBP) In addition to Standard Precautions, (EBP) will be used when Contact Precautions do not otherwise apply .It employs targeted personal protective equipment [PPE] use during high contact patient/resident .activities is .Implementation of EBP .Patient Status .a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained . Record review of the facility procedure for EBP last revised on 5/1/2025 states in part, 1. Post the appropriate Enhanced Barrier Precautions sign on the patient's room door . 1.3 Print precaution signs in color .Follow the Centers for Disease Control and Prevention (CDC) guidance table below. 'Precautions .Enhance Barrier All patients with any of the following .Chronic wounds and /or indwelling medical devices (e.g, central line, urinary catheter, enteral feeding tube .PPE used for these situations .During high contact patient care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use, central line, urinary catheter Wound care: any skin opening requiring a dressing .' A. Record review revealed Resident ID #34 has a diagnosis including, but not limited to, a blister on the right foot. Record review revealed a physician's order dated 5/1/2025 to cleanse the opened blister to the right heel, pat dry, apply skin prep around the wound and cover with a bordered gauze daily. B. Record review revealed Resident ID #47 has a diagnosis including, but not limited to, an open wound to the right lower leg. Record review revealed a physician's order dated 4/2/2025 for Fluocinonide External Cream 0.05 % (a topical medication prescribed to treat skin conditions that involve inflammation), apply to the right lower leg daily for bullous pemphigoid (an autoimmune skin disorder characterized by the formation of large, blisters that can rupture and leave open sores) for 8 Weeks. C. Record review revealed Resident ID #88 has diagnoses including, but not limited to, obstructive and reflux uropathy (a condition where the urine flow is blocked in the urinary tract), open wound of the scalp, a history of urinary tract infections, encounter for fitting and adjustment of urinary devices and need for assistance with personal care. Record review of the physician's orders revealed the following: - 5/8/2025, Cleanse scalp wound with NS (normal saline; a mixture of salt and water), pat dry and cover with a bordered gauze dressing daily - 7/21/2023, Empty the urinary catheter drainage bag at least once every eight hours when it becomes 1/2 to 2/3 full Surveyor observations of the Homestead Unit failed to reveal evidence that the above-mentioned residents had the appropriate EBP signage on the doors to their rooms, on the following dates and times: - 5/12/2025 at 10:14 AM, 10:20 AM, 12:00 PM, 12:30 PM, 2:18 PM, 2:28 PM, 3:05 PM and 3:26 PM - 5/13/2025 at 8:11 AM, 8:38 AM, 10:54 AM, 11:16 AM, 12:07 PM, 1:54 PM, 4:45 PM and 5:06 PM - 5/14/2025 at 9:11 AM, 9:31 AM, 11:16 AM, and 3:02 PM During a surveyor interview on 5/14/2025 at 9:11 AM with Nursing Assistant (NA), Staff N, he revealed that he has been taking care of the residents on this unit who have urinary catheters and wounds. Additionally, Staff N was unaware that the residents should have been on EBP and required PPE when he provided direct care to them. During a surveyor interview on 5/14/2025 at 1:58 PM with the Unit Manager, Registered Nurse, Staff M, she acknowledged that there are no signs indicating that the above-mentioned residents were on EBP. Furthermore, Staff M revealed that she would expect any resident with a urinary catheter and/or wounds would have been placed on EBP and signage should have been placed on their door. Additionally, she would expect that whenever staff provides direct care to residents with catheters or wounds they should wear the appropriate PPE. During a surveyor interview on 5/14/2025 at 2:06 PM with NA, Staff O, she revealed that she has not received training on EBP and was unaware that any of the residents on the Homestead Unit required EBP. During a surveyor interview on 5/14/2025 at 2:26 PM and at 2:35 PM with the Clinical Market Advisor, he revealed that he would expect resident's with wounds, gastrostomy tubes, and urinary catheters to be placed on EBP and that staff would utilize PPE when providing direct care.

Based on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 3 of 7 medication carts observed, and for 2 of 3 medication rooms. Findings are as follows: According to the facility policy titled, Disposal of Medication Waste dated 7/1/2024, states in part, .All medications will be disposed of in accordance with applicable federal, state and local regulations . Medications for disposal include: -Medications which are not taken with the patient upon discharge; -Discontinued, expired, or contaminated medications not returned to the pharmacy . 1a. A surveyor observation on 5/13/2025 at 4:45 PM of the Homestead Unit medication cart, revealed a medicine cup with one round white pill on top of the medication cart located in the hallway, unattended. Certified Medication Technician (CMT), Staff K, was observed exiting the restroom and walking towards the medication cart. During a surveyor interview immediately following the above observation with CMT, Staff K, she revealed that she dispensed 3 Tylenol tablets and placed one of the tablets in a cup and left the cup on the medication cart. Staff K acknowledged that she should have discarded the pill and should not have left it unattended on the medication cart. 1b. A surveyor observation on 5/14/2025 at approximately 8:30 AM of the Avenue Unit medication cart, in the presence of Registered Nurse (RN), Staff A, revealed the following: -1 Lantus insulin pen, opened without a date. Manufacturer's instructions state to discard 28 days after opening. -1 Lantus insulin pen, opened with a date of 2/11. Manufacturer's instructions state to discard 28 days after opening. -1 Breo Ellipta inhaler, opened without a date, manufacturer's instructions state to discard 6 weeks after opening. -1 Active Liquid Protein, (with the majority of the contents consumed) opened without a date. Manufacturer's instructions state to discard 3 months after opening. During a surveyor interview with Staff A immediately following the above observations, she acknowledged that the Lantus insulin pen had a date of 2/11 and that it was expired. Additionally, she acknowledged that the remaining above-mentioned medications were opened, without a date and should have been dated when opened. 2a. A surveyor observation on 5/14/2025 at approximately 8:30 AM of the Transitional Care Unit medication room, in the presence of Licensed Practical Nurse, Staff H, revealed the following: -2 Kayexalate bottles in the medication cabinet, prescribed for a resident that no longer resides on the unit. -1 box of Lovenox 30 milligram (mg) injections, 7 injections remaining, prescribed for a resident that no longer resides on the unit. During a surveyor interview with Staff H, she indicated that they should have been placed in the discarded medication bin. 2b. A surveyor observation on 5/14/2025 at 9:00 AM of the M Nurses Station medication room refrigerator, revealed the following: -1 Lispro insulin pen, opened without a date. Manufacturer's instructions state to discard 28 days after opening. During a surveyor interview immediately following the above observation with RN Staff L, she acknowledged that the Lispro insulin pen was open without a date and that it should have been dated when opened and was going to be discarded. 2c. A surveyor observation on 5/14/2025 at 9:50 AM of the Homestead medication room refrigerator revealed the following: -1 bottle of Lorazepam Intensol, with an expiration date of 5/6 written on the medication box. During a surveyor interview with RN, Staff M, she acknowledged that the Lorazepam medication was expired and should have been discarded. During a surveyor interview on 5/14/2025 at 2:19 PM with the Assistant Director of Nursing Services, she acknowledged the above-mentioned medications were not dated when opened, that the expired medications were still in use and the prescribed Kayexalate and Lovenox were located in the medication storage cabinet and should have been discarded.

Based on record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments, and considering the number, acuity, and diagnoses of the facility's resident population, in accordance with the facility assessment, for 4 of 4 nurses reviewed, Staff B, D, E and F. Additionally, the facility failed to have the appropriate competencies and skill sets relative to a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous [IV] fluids and medications), for 3 of 3 nurses reviewed, Staff G, H, and I. Findings are as follows: Record review of the Facility Assessment dated 2/12/2025, states in part, .Center staff .receive initial training .staff training/competency/skill sets are sets that are necessary to provide the level and types of care needed for the patient/resident population .yearly .and as necessary .the following is a breakdown of departments and the area in which they receive competencies. Licensed Nurses .I.V. skills .PPE [personal protective equipment], infection control .catheters, G-tube [gastrostomy tube; a flexible tube inserted through the abdominal wall] . 1. Record review failed to reveal evidence that the following staff had completed annual nursing competencies since 2023: - Registered Nurse (RN) Staff E, hired in March of 2009 - RN Staff B, hired in March of 2023 - RN Staff F, hired in August of 2023 - RN Staff G, hired in May of 2016 2. Record review of the facility assessment revealed that the facility provides services for the resident population including, but are not limited to, IV therapy. Further review of the assessment requires staff to be competent in this skill set. Record review of the education/competency files for Staff H, I and J failed to reveal evidence that they had completed their yearly IV competency to manage and administer medications via a PICC line, per the facility assessment. - Licensed Practical Nurse (LPN) Staff H, hired in May of 2016 - LPN Staff I, hired in October of 2006 - RN Staff J, hired in December of 2020 During a surveyor interview on 5/14/2025 at 5:07 PM with the Clinical Market Advisor, he was unable to provide evidence that any of the above-mentioned staff members had completed their yearly competencies according to the facility assessment, as required. Cross reference F 694

Based on record review and staff interview, it has been determined that the facility failed to ensure that the irregularities identified by the Clinical Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 3 of 6 residents reviewed, Resident ID #s 29, 76 and 96. Findings are as follows: 1. Record review for Resident ID #29 revealed a physician's order dated 2/21/2025 for Lantus insulin (a medication prescribed to lower blood sugar), 16 units daily at bedtime, and Sitagliptin (a medication prescribed to treat type 2 diabetes mellitus), 150 milligrams (mg) daily. Record review of the pharmacist's MRR, dated 4/15/2025, revealed the following recommendations: - to consider decreasing the resident's Lantus insulin 16 unit dose at bedtime, by 2 units - to evaluate the Sitagliptin 150 mg daily dose, as it exceeds the maximum recommended manufacturer's dosing of 100 mg daily 2. Record review for Resident ID #76 revealed a physician's order dated 2/6/2025 for lorazepam (a medication prescribed to treat anxiety disorders) 0.5 mg every 6 hours as needed (PRN). Record review of the pharmacist's MRR, dated 4/15/2025, revealed a recommendation to evaluate the resident's current diagnosis, behavior, usage pattern, and his/her continued need for the medication. Additional recommendations were made to discontinue the order or indicate the duration of the PRN order. 3. Record review for Resident ID #96 revealed the following physician's orders: - two duplicate orders of phenazopyridine (a medication prescribed to relieve pain or irritation of the urinary tract), 200 mg every 8 hours PRN - acetaminophen (a medication prescribed to relieve mild to moderate pain), 1000 mg every 8 hours PRN - aspirin-acetaminophen-caffeine (a medication prescribed to relieve a headache), 250mg-250mg-65mg PRN daily - Miralax (a medication prescribed to treat constipation) oral powder 17 grams, twice daily Record review of the pharmacist's MRR, dated 4/15/2025, revealed the following recommendations: - to consider discontinuing one of the duplicate PRN phenazopyridine orders - to write an order for clarification to include parameters not to exceed a maximum total dosage of 3 grams of the medications containing acetaminophen - to consider adding an order to mix the Miralax with 4 to 8 ounces of fluid per dose Record review for Resident ID #s 29, 76 and 96 failed to reveal evidence that the monthly MRRs, with noted irregularities, were reviewed and acted upon by the resident's provider. During a surveyor interview on 5/14/2025 at approximately 5:30 PM with the Clinical Market Advisor and the Assistant Director of Nurses, they were unable to provide evidence that the pharmacy consultation reports were reviewed by the provider and acted upon, as required.

Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who requires dialysis (a treatment that filters blood when kidneys fail to adequately remove fluids and waste) receive such services consistent with professional standards of practice and the comprehensive person-centered care plan, for 1 of 1 resident reviewed receiving dialysis, Resident ID #83. Findings are as follows: Record review of a facility policy titled, Dialysis: Hemodialysis External Catheter Evaluation and Maintenance last revised 5/1/2025, states in part, .The licensed nurse will ensure that the dialysis access site (e.g. AV shunt or graft [a synthetic tube used to surgically connect the artery and vein, used for dialysis access]) is checked before and after dialysis treatment and every shift for patency [free from blockage or open] by auscultating for bruit [whooshing or swishing sound heard with a stethoscope] and palpating [feeling] for a thrill [a vibration felt with the fingertips when touching the AV shunt or graft] . Record review revealed the resident was admitted to the facility in April of 2023 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Record review of a care plan initiated on 4/5/2023, revealed the resident is at risk for complications related to hemodialysis with an intervention in place to monitor the dialysis access site for a positive bruit and a positive thrill, every shift and as needed. Record review failed to reveal evidence of a physician's order to monitor the dialysis access site for a positive bruit and a positive thrill every shift. Record review of the progress notes revealed 9/21/2024 was the last time the dialysis site was assessed for a positive bruit and a positive thrill. During a surveyor interview on 5/13/2025 at 3:57 PM with Registered Nurse, Staff D, she acknowledged that the resident did not have an order to monitor for a positive bruit and thrill, as indicated per the facility policy. Further review of the record revealed a physician's order was obtained on 5/13/2025 to check for a positive bruit and thrill to the left arm, after the concern was brought to the facility's attention by the surveyor. During a surveyor interview on 5/14/2025 at 3:07 PM with the Clinical Market Advisor, he indicated that he would have expected an order to be initiated to monitor the resident's dialysis access site for a positive bruit and thrill on every shift and as needed.

Based on surveyor observation, staff and resident interview, it has been determined that the facility failed to provide, based on the comprehensive assessment, care plan and the residents' preferences's, an ongoing program to support the residents' choice of activities which reflect the residents' interests, for 3 of 3 residents reviewed that were unable to watch television in their room from 5/9/2025 through 5/13/2025, Resident ID #'s 2, 86, and 99. Findings are as follows: 1. Record review revealed Resident ID #2 was admitted to the facility with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (a chronic lung disease that causes damage to the lungs). Record review of his/her Annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review of the MDS, Section F, revealed that it is very important to the resident to keep up with the news. Record review of a care plan dated 11/21/2022 revealed a focused area for opportunity to engage in daily routines that are meaningful to his/her preferences with the following interventions in place: - I keep up with the news by reading the newspaper, and watching TV - I like to look out the window, lay down/rest, pray, read, think, watch TV, crossword search, adult coloring by myself - I enjoy watching/listening TV During a surveyor interview on 5/12/2025 at 12:57 PM with the resident, s/he indicated that the television in his/her room has not worked since Friday 5/9/2025. S/he indicated that s/he was unhappy over the weekend without a television to watch the news or any movies. 2. Record review revealed Resident ID #86 was admitted to the facility with a diagnosis including, but not limited to, wedge compression fracture of the first lumbar (type of fracture where the front part of the vertebra collapses causing a wedge shape). Record review of his/her admission MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15, indicating intact cognition. Further review of the MDS, Section F, revealed that it is somewhat important to the resident to keep up with the news. Record review of his/her care plan dated 12/2/2024, revealed a focused area for the opportunity to engage in daily routines that are meaningful relative to the resident's preferences with the following interventions: - I keep up with the news by watching TV - I enjoy watching/listening TV - I like to watch TV/movies by myself in my bedroom During a surveyor interview on 5/12/2025 at 12:48 PM with the resident, s/he indicated that the television in his/her room has not worked for several days and s/he was left with nothing to do. 3. Record review revealed Resident ID #99 was admitted to the facility with a diagnosis including, but not limited to, metabolic encephalopathy (a brain disorder that results from a disturbance in metabolism, causing brain dysfunction). Record review of his/her Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Record review of his/her care plan dated 8/15/2024 revealed a focused area to engage in daily routines that are meaningful and preferred, with an intervention including, but not limited to, watching and listening to TV. During a surveyor interview on 5/12/2025 at 12:57 PM with the resident, s/he indicated that the television does not work due to an electrical issue with the plug for the television. S/he revealed that s/he was very upset especially over the weekend when there were no activities. During a surveyor interview on 5/13/2025 at 8:27 AM with the Maintenance Director, he revealed that he was aware of the power outage, effecting the above-mentioned residents outlets. During a surveyor interview on 5/14/2025 at 3:07 PM with the Clinical Market Advisor, he revealed it was his expectation that the residents effected by the power outage, should have been offered and provided a tablet to watch television or movies.

Based on surveyor observation, record review, and staff and resident interview, it has been determined that the facility failed to ensure that a resident receives care, consistent with professional standards of practice to prevent pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure) for 1 of 2 residents reviewed, Resident ID #43. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2025 with diagnoses including, but not limited to, right femur fracture and osteoarthritis. During a surveyor interview with the resident on 5/12/2025 at 11:27 AM, s/he revealed that s/he has bed sores on his/her buttocks and the areas are red. Additionally, s/he revealed that they sometimes apply a cream to both his/her butts. Record review revealed a care plan dated 4/28/2025 indicating that the resident is at risk for skin breakdown, with interventions that include, but are not limited, to the following: - Provide preventative skin care as ordered - Weekly skin check by licensed nurse Record review of the admission Minimum Data Set assessment dated [DATE] revealed, the resident is non ambulatory and requires moderate assistance from staff for bed mobility, transferring, hygiene, and dressing. Record review of the point of care documentation, completed by the nursing assistants revealed an Intervention/Task for preventative skin care ie. creams/lotions every shift. Further review of the document revealed that staff failed to provide preventative skin care for 32 out of 36 opportunities for the month of May. Record review of the weekly skin assessments revealed a skin check was completed on 5/1/2025, indicating no skin impairment. Further review of the weekly skin checks failed to reveal evidence that a weekly skin check was completed after 5/1/2025. During a surveyor interview on 5/13/2025 at 12:25 PM with Registered Nurse (RN) Staff B, she acknowledged that the last skin assessment was completed on 5/1/2025 and that a skin assessment should have been completed on 5/8/2025. Staff B was unable to provide evidence that a skin check was completed after 5/1/2025. During a subsequent interview and simultaneous observation of the resident's skin with Staff B, on 5/13/2025 at 12:27 PM, the resident expressed that s/he has bed sores on his/her buttocks. Additional observation of the resident revealed the skin to his/her buttocks was pink, with a blanchable area noted on each buttock cheek, approximately the size of a quarter. Furthermore, Staff B acknowledged the above observations. During a surveyor interview on 5/14/2025 at 11:13 AM with the facility Wound Nurse, she revealed that typically residents needing preventative skin care are those that have intact blanchable redness, have had a previous pressure injury, and/or impaired mobility. During a surveyor interview with the Assistant Director of Nursing on 5/14/2025 at 5:08 PM, she was unable to provide evidence that a weekly skin assessment was completed for the resident after 5/1/2025. Additionally, she indicated that she would have expected that a skin assessment would be completed weekly.

Based on record review and staff interview, it has been determined that the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 5 residents reviewed, who experienced an actual weight loss and the facility failed to follow their own policy relative to weight monitoring, Resident ID #173. Findings are as follows: Review of a facility policy titled Weights and Heights states in part, .Obtaining and Documenting Weight: 1.1 A licensed nurse or designee will weigh the patient. 1.1.1 Admissions and re-admissions will be weighed within 24 hours of admission . 1.1.4 If the body weight is not expected, re-weigh the patient . 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment . 2.2 The licensed nurse will: 2.2.1 Notify the physician .Dietitian of significant weight changes . Record review revealed the resident was admitted to the facility in April of 2025 with diagnoses including, but not limited to, sepsis due to Enterococcus (a bacteria that enters the bloodstream and may cause a widespread inflammatory response), and diabetes mellitus. Record review revealed the Registered Dietitian completed a nutritional admission assessment on 5/1/2025. Review of a care plan dated 5/1/2025 revealed the resident is at nutritional risk related to a therapeutic diet. Further review of the care plan revealed interventions to provide his/her diet as ordered, and offer him/her snacks. Record review revealed a physician's order with a start date of 5/2/2025 for weekly weights for 4 weeks. Record review revealed the following weights were obtained: - 4/29/2025 (admission weight): 224.8 pounds (lbs.) - 5/3/2025: 222.0 lbs. - 5/4/2025: 220.0 lbs. - 5/5/2025: 218.4 lbs. - 5/6/2025: 216.0 lbs. - 5/7/2025: 217.4 lbs. - 5/9/2025: 213.0 lbs. - 5/10/2025: 210.8 lbs. - 5/12/2025: 208.4 lbs. - 5/13/2025: 209.7 lbs. Record review revealed the resident experienced a 6.7% (15.1 lbs.) significant weight loss in less than one month, from 4/29/2025 to 5/13/2025. Record review failed to reveal evidence that a nutritional intervention was implemented. During a surveyor interview on 5/14/2025 at 3:30 PM with the RD, she revealed that she was unaware of the resident's significant weight loss. Additionally, she revealed that if she had been notified of the resident's significant weight loss she would have implemented an intervention of fortified foods. Lastly, she revealed she would assess the resident more often, as s/he has had a significant weight loss. During a surveyor interview on 5/14/2025 at 4:47 PM with the resident's physician, he revealed that he was not aware of the extent of the resident's weight loss. Additionally, he revealed that he saw the resident today and would review his/her record later that day. During a surveyor interview on 5/14/2025 at 2:25 PM with the Assistant Director of Nursing, she revealed that the computer system will trigger when a weight loss is identified at 5%, 7.5% and 10% and further revealed that when a weight loss percentage is triggered, a reweigh should be obtained that day or the next.

Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of practice, in accordance with physician orders and the comprehensive person-centered care plan, for 1 of 1 resident reviewed who was receiving antibiotics via a peripherally inserted central catheter (PICC; a long flexible tube that is inserted into a vein in the arm and threaded through a larger vein leading to the heart, used to administer intravenous (IV) fluids and medications), Resident ID #173. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, enterococcal bacteremia (a bacteria that enters the bloodstream and may cause a widespread inflammatory response). Record review revealed the resident was receiving the following antibiotics: -Ampicillin (an antibiotic prescribed to treat various infections) 2 grams intravenously, every 4 hours. -Ceftriaxone (an antibiotic prescribed to treat various infections) 2 grams intravenously, every 12 hours. Record review revealed a physician's order dated 5/6/2025 to change the PICC catheter site dressing weekly. Additional review revealed to indicate the external catheter length and the upper arm circumference (10 centimeters (cm) above the antecubital [the front of the elbow]) and to notify the practitioner if the external length of the catheter has changed since the last measurement. Record review of the hospital continuity of care document revealed the resident had a PICC line placed on 4/26/2025. Further review of the hospital paperwork failed to reveal measurements relative to the PICC line including, external catheter length or the upper arm circumference measurements. Record review of the May 2025 Medication Administration Record (MAR), revealed the PICC line dressing change was signed off as completed with the initials of Registered Nurse (RN) Staff C, on 5/6/2025 and 5/13/2025. Additionally, the MAR failed to reveal evidence of an external catheter length measurement or the upper arm circumference measurement. Further record review failed to reveal evidence of measurements for the PICC line's external catheter length or the right upper arm circumference for the dates of 5/6, 5/12 or 5/13/2025. Surveyor observations of the resident's PICC line dressing to his/her right upper arm on 5/12/2025 and on 5/14/2025 revealed the dressing that was dated 5/12 with the initials of a different nurse. During a surveyor interview with the Clinical Market Advisor on 5/14/2025 at 12:40 PM, he was unable to provide evidence of measurements for the resident's PICC line that included the external catheter length or the right upper arm circumference. During a surveyor interview with the Assistant Director of Nursing Services (ADNS) on 5/14/2025 at 3:14 PM, she revealed that the PICC line dressing was changed on 5/12/2025 because the dressing was lifting. During a surveyor interview on 5/14/2025 at 3:45 PM with Staff C, she indicated that she signed off that she had completed the PICC line dressing changes in error on 5/6/2025 and again on 5/13/2025. Additionally, she revealed that she has never changed the resident's PICC line dressing. Cross reference F 726

Based on surveyor observation, record review, and staff and resident representative interview, it has been determined that the facility failed to ensure that the residents' environment remains as free of accident hazards as is possible for residents residing on a secured memory care unit relative to controlled substances and sharps contraband for 2 residents reviewed, Resident ID's #1 and #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/31/2022 revealed that a resident's family member went into the resident's room to visit when they observed a razor blade and a white powdery substance on a mirror on the bedside table. The report further indicated that the family member brought the paraphernalia (equipment that is used to consume illicit drugs) to the nurse at the nurse's station. The Director of Nursing Services (DNS) and the police were made aware. Additionally, the report revealed that the police questioned the aide that was assigned to care for the resident, Certified Nursing Assistant (CNA) Staff A, and she admitted to the paraphernalia being hers, she was arrested and removed from the facility. Review of a facility policy titled Substance Abuse and Alcohol Misuse Prevention and Testing last revised on 7/01/2022 revealed in part, .This policy applies to all applicants and employees .Company policy strictly prohibits the illegal use, solicitation, sale, sharing, or possession of narcotics, drugs, paraphernalia, alcohol, or controlled substances while on the job or on Company property .Purpose .To provide and maintain a safe, drug-free environment for all employees and patients/residents and to protect the Company's assets . Surveyor observation of the secured memory care unit at the facility on 1/04/2023 revealed ambulatory resident's walking up and down the hallway intermittently stopping at resident room doorways. 1. Record review for Resident ID #1 revealed that s/he was originally admitted to the facility in May of 2017 and has diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The assessment further indicated that the resident is ambulatory. Review of a progress note date 12/31/2022 at 3:38 PM revealed in part, Residents poa [power of attorney] .notified that an aide on unit today had illegal narcotic substance and paraphernalia on unit police were immediately notified arrived on unit spoke w/aide [with aide] whom admitted drugs and paraphernalia were hers . During a surveyor phone interview with the resident representative on 1/04/2023 at 10:45 AM, s/he revealed that when s/he entered the resident's room for a daily visit, s/he observed a mirror with a razor blade and a white powdery substance on the bedside table. The family representative further indicated that s/he brought it to the nurse at the nurse's station and made them aware of where it was found. Additionally, the representative indicated that a person taking illegal narcotics is unsafe and should not be caring for the residents. 2. Record review for Resident ID #2 who is a roommate of Resident ID #1 revealed that s/he was originally admitted to the facility in December of 2018 and has diagnoses including, but not limited to, Parkinson's disease and Neurocognitive disorder with Lewy Body dementia. Review of the resident's MDS assessment dated [DATE] revealed that the resident is rarely or never understood, has severe cognitive impairment, and displays wandering behaviors. The assessment further indicated that the resident is ambulatory. Review of a progress note dated 12/31/2022 at 3:29 PM revealed in part, Resident's spouse notified that an aide on unit today was found w/ [with] illegal narc [narcotic] substance and paraphernalia on unit, substance was found in [residents room] on tray table, police were notified .aide admitted that drugs and paraphernalia were hers . During a surveyor interview with Licensed Practical Nurse, Staff B, on 1/04/2023 at 11:06 AM, she revealed that she has been employed at the facility for [AGE] years and she indicated that some of the resident's on the memory care unit are ambulatory, that this situation was unsafe, and could have resulted in a very dangerous situation. During a surveyor phone interview with Registered Nurse Staff C on 1/04/2023 at 12:32 PM, she revealed that while she was sitting at the nurse's station on 12/31/2022 a family representative approached her and placed a mirror with a razor blade and a white powdery substance on it in front of her stating s/he found this in resident's room on the bedside table. Staff C further indicated that the DNS was made aware, and the police arrived at the facility and interviewed Staff A who was assigned to care for the resident. Additionally, Staff C revealed that Staff A admitted to the police officers that the white powdery substance which the police identified as cocaine and the razor blade belonged to her. Review of a police report for Staff A dated 12/31/2022 revealed in part, Staff A .admitted to bringing the cocaine to work this morning in her scrubs. She stated she was assisting [resident representative's] [parent] and she felt the razor in her pocket. She removed the items from her pocket, placed them on the small table, and forgot remove them from when she left . During a surveyor interview with the DNS on 1/04/2023 at 8:40 AM she revealed Staff A was assigned to care for the resident on 12/31/2022. The DNS further indicated that Staff A admitted to the police that the cocaine and razor blade that was found in the resident's room on the secured memory care unit by the resident's family member belonged to her. In a subsequent interview with the DNS on 1/04/2023 at approximately 1:15 PM, she acknowledged that this situation was unsafe, and she is unsure of what may have occurred if the resident's family member had not noticed the razor blade and the white powdery substance in the resident's room and brought it to the facility's attention.

Based on surveyor observation, record review, and staff and resident representative interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on the secured memory care unit relative to controlled substances and sharps contraband, Resident ID's #1 and #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/31/2022 revealed that a resident's family member went into the resident's room to visit when they observed a razor blade and a white powdery substance on a mirror on the bedside table. The report further indicated that the family member brought the paraphernalia (equipment that is used to consume illicit drugs) to the nurse at the nurse's station. The Director of Nursing Services (DNS) and the police were made aware. Additionally, the report revealed that the police questioned the aide that was assigned to care for the resident, Certified Nursing Assistant (CNA) Staff A, and she admitted to the paraphernalia being hers, she was arrested and removed from the facility. Review of a facility policy titled Substance Abuse and Alcohol Misuse Prevention and Testing last revised on 7/01/2022 revealed in part, .This policy applies to all applicants and employees .Company policy strictly prohibits the illegal use, solicitation, sale, sharing, or possession of narcotics, drugs, paraphernalia, alcohol, or controlled substances while on the job or on Company property .Purpose .To provide and maintain a safe, drug-free environment for all employees and patients/residents and to protect the Company's assets . Surveyor observation of the secured memory care unit at the facility on 1/04/2023 revealed ambulatory resident's walking up and down the hallway intermittently stopping at resident room doorways. 1. Record review for Resident ID #1 revealed that s/he was originally admitted to the facility in May of 2017 and has diagnoses including, but not limited to, dementia and cognitive communication deficit. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The assessment further indicated that the resident is ambulatory. Review of a progress note date 12/31/2022 at 3:38 PM revealed in part, Residents poa [power of attorney] .notified that an aide on unit today had illegal narcotic substance and paraphernalia on unit police were immediately notified arrived on unit spoke w/aide [with aide] whom admitted drugs and paraphernalia were hers . During a surveyor phone interview with the resident representative on 1/04/2023 at 10:45 AM, s/he revealed that when s/he entered the resident's room for a daily visit, s/he observed a mirror with a razor blade and a white powdery substance on the bedside table. The family representative further indicated that s/he brought it to the nurse at the nurse's station and made them aware of where it was found. Additionally, the representative indicated that a person taking illegal narcotics is unsafe and should not be caring for the residents. 2. Record review for Resident ID #2 who is a roommate of Resident ID #1 revealed that s/he was originally admitted to the facility in December of 2018 and has diagnoses including, but not limited to, Parkinson's disease and Neurocognitive disorder with Lewy Body dementia. Review of the resident's MDS assessment dated [DATE] revealed that the resident is rarely or never understood, has severe cognitive impairment, and displays wandering behaviors. The assessment further indicated that the resident is ambulatory. Review of a progress note dated 12/31/2022 at 3:29 PM revealed in part, Resident's spouse notified that an aide on unit today was found w/ [with] illegal narc [narcotic] substance and paraphernalia on unit, substance was found in [residents' room] on tray table, police were notified .aide admitted that drugs and paraphernalia were hers . During a surveyor interview with Licensed Practical Nurse Staff B on 1/04/2023 at 11:06 AM, she revealed that she has been employed at the facility for [AGE] years and she indicated that some of the resident's on the memory care unit are ambulatory, that this situation was unsafe, and could have resulted in a very dangerous situation. During a surveyor phone interview with Registered Nurse Staff C on 1/04/2023 at 12:32 PM, she revealed that while she was sitting at the nurse's station on 12/31/2022 a family representative approached her and placed a mirror with a razor blade and a white powdery substance on it in front of her stating s/he found this in resident's room on the bedside table. Staff C further indicated that the DNS was made aware, and the police arrived at the facility and interviewed Staff A who was assigned to care for the resident. Additionally, Staff C revealed that Staff A admitted to the police officers that the white powdery substance which the police identified as cocaine and the razor blade belonged to her. Review of a police report for Staff A dated 12/31/2022 revealed in part, Staff A .admitted to bringing the cocaine to work this morning in her scrubs. She stated she was assisting [resident representative's] [parent] and she felt the razor in her pocket. She removed the items from her pocket, placed them on the small table, and forgot remove them from when she left . During a surveyor interview with the DNS on 1/04/2023 at 8:40 AM she revealed Staff A was assigned to care for the resident on 12/31/2022. The DNS further indicated that Staff A admitted to the police that the cocaine and razor blade that was found in the resident's room on the secured memory care unit by the resident's family member belonged to her. In a subsequent interview with the DNS on 1/04/2023 at approximately 1:15 PM, she acknowledged that this situation was unsafe, and she is unsure of what may have occurred if the resident's family member had not noticed the razor blade and the white powdery substance in the resident's room and brought it to the facility's attention.

Based on record review and staff interview, it has been determined that the facility failed to ensure a physician review the resident's total program of care, including medications and treatments, at each visit, for 1 of 6 new admissions reviewed, Resident ID #108. Findings are as follows: According to Healthline.com, [MEDICATION(S)] toxicity is another term for a [MEDICATION(S)] overdose. It occurs when you take too much [MEDICATION(S)] .A safe blood level of [MEDICATION(S)] is 0.6 to 1.2 milliequivalents per liter (mEq/L). [MEDICATION(S)] toxicity can happen when this level reaches 1.5 mEq/L or higher. Severe [MEDICATION(S)] toxicity happens at a level of 2.0 mEq/L and above .Symptoms of mild to moderate [MEDICATION(S)] toxicity include: Fatigue tremors uncontrollable movements muscle weakness drowsiness weakness . Serum levels of [MEDICATION(S)] above 2.0 mEq/L can cause severe toxicity and additional symptoms, including: heightened reflexes seizures agitation slurred speech kidney failure rapid heartbeat hyperthermia uncontrollable eye movements low blood pressure confusion coma [CONDITION(S)] death Review of a facility reported incident received by the Rhode Island Department of Health on 5/17/2022 states in part, .[Patient] .admitted to ICU .on 4/25/22 from .hospital .on [MEDICATION(S)] prior to admission per the COC [continuity of care form; form that summarizes patient information and helps providers communicate clinical information during transitions of care] .from .[hospital] [patient] [to] receive [MEDICATION(S)] 300mg controlled release every other day, admitting nurse .put in order on 4/25/22 to admin [MEDICATION(S)] 300mg (milligrams) ER [extended release] [daily] at bedtime .on 5/15/22 [patient] presented [with] lethargy stat [urgent] labs ordered and reviewed by on call clinician, and again by [Nurse Practitioner] .in [morning] on 5/16/22 .[MEDICATION(S)] level elevated @[2.03] [mEq/L] BUN @48 [blood urea nitrogen, normal range is 6 to 24 mg/dL, mg per deciliter] son .reccommended [sic] pt. be sent out to .[emergency department] for [evaluation and/or treatment] . Review of a community reported complaint received by RIDOH on 5/18/2022 states in part, My complaint is submitted below in its specific elements and in order of severity; 1.) [Resident ID #108] was administered [his/her] [MEDICATION(S)] medication of 300 mg every day instead of every other day as directed in [his/her] medication information starting on 4/25/22. This was discovered on 5/16/22 after I visited [resident] on 5/15/22 and found [him/her] in a drastically altered state and unable to speak and properly control [his/her] arm movements while attempting to drink from a cup. [S/he] could barely get [his/her] hand to [his/her] mouth to eat .At 11:00 am I requested the [Doctor] on staff and advised him that something was way out of line as [the resident] was not exhibiting these difficulties only a week earlier. The [Doctor] examined [the resident] and confirmed the involuntary motions and the inability of [him/her] to speak properly. The [Doctor] advised he would order blood work to be done. I was concerned about medicine .The current result of this unacceptable oversight is my .[parent] is in the .Hospital and being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . I ordered [him/her] to the emergency roiagnom on the night of 5/16/22 after a family decision was made to no longer allow the [facility] to continue [his/her] care .It was my action on 5/15/22 that lead to the discovery of the unacceptable administration of my [parent's] medication at the [facility] . Record review revealed the resident was admitted to the facility from an acute care hospital in April of 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's continuity of care form from the hospital discharge date d 4/25/2022 revealed in part: CONTINUE taking these medications with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Every other night. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .at bedtime for Mood Disorder -Start Date 04/25/2022 . Review of the resident's medication administration record (MAR) revealed s/he received [MEDICATION(S)] [MEDICATION(S)] ER Tablet Extended Release 300 MG, nightly from 4/26/2022 through 5/15/2022, indicating s/he received 10 additional doses of this medication. Review of the resident's progress notes revealed an entry from the Nurse Practitioner, signed on 4/27/2022 at 8:11 AM which indicates to continue [MEDICATION(S)] [MEDICATION(S)] ER 300mg one capsule at bedtime. Review of the resident's progress notes revealed a Physician Narrative H&P (history and physical) by the resident's physician on 4/27/2022 at 7:46 PM which states in part, .[CONDITION(S)] II and Depression: stable at baseline at this time and will continue with the [MEDICATION(S)] . Review of the resident's progress notes revealed a Physician Narrative H&P by the resident's physician on 5/4/2022 at 6:07 PM revealed in part, .Reviewed the [facility name] chart including, active Medications, Past Medical History, Social History, Family History and Laboratory results .[CONDITION(S)] disorder: [S/he] is stable at this time at [his/her] baseline without any issues and we will continue to monitor . During an interview with the physician on 5/17/2022 at 12:30 PM he revealed that he did not identify that the [MEDICATION(S)] order was transcribed incorrectly from what was written on the COC form. He further indicated that while he does check to make sure that every medication is listed, he doesn't review the dose and frequency of every medication for each resident unless there is a concern. Additionally, he revealed that when he saw the resident on 5/15/2022 s/he was weak and tremulous. During an interview on 5/17/2022 at 12:55 PM with the Nurse Practitioner, she revealed that she does look at the COC form and then goes back to verify against the orders at a different time. Stating, as an example, that if she forgot to write down the [MEDICATION(S)] dose that she may look at the electronic medical administration record to verify. She further revealed that when she referred to [MEDICATION(S)] daily in her progress note, she probably got that information from the facility's MAR and not the hospital's COC form. Record review of the resident's laboratory results revealed the following: -4/26/2022 -[MEDICATION(S)] level, 0.44 MMOL/L (millimoles per liter) (reference range 0.50-1.50) -5/15/2022 -[MEDICATION(S)] level, 2.03 MMOL/L. This is a toxic level. Further review of the resident's progress notes revealed the following entry dated 5/16/2022, time stamped 6:00 PM, states in part, .re-reviewed [MEDICATION(S)] med error, elevated [MEDICATION(S)] levels, and patients recent increase in lethargy with .[Nurse Practitioner] .[family member] called and expressed concerns regarding [Nurse Practitioner's] plan [related to] [MEDICATION(S)] level .Spoke with Patients son .again to follow up regarding additional orders/plan of care .patients son not agreeable and states at this time he would like to send patient to [hospital] .patient transported as requested . Review of a progress note dated 5/16/2022 at 7:38 PM revealed the resident was transported to the hospital. Record review of the hospital admission paperwork dated 5/16/2022 at 9:54 PM states in part under assessment and plan, .[MEDICATION(S)] toxicity #h/o [history of] [CONDITION(S)] Supposed to be on [MEDICATION(S)] every other day. Has been getting it daily for almost a month. [MEDICATION(S)] level elevated on admission -poison control consulted -gentle IV hydration -repeat [MEDICATION(S)] level STAT, if elevated, will repeat [every 2 hours] . During a surveyor interview on 5/17/2022 at 12:04 PM with the Director of Nursing Services and the Administrator, they were unable to provide evidence that the physician and [Nurse Practitioner] reviewed the resident's total program of care, including medications as required.

Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 14 residents reviewed, Resident ID #108. Findings are as follows: According to State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, an unnecessary drug is any drug when used in excessive dose (including duplicate drug therapy); or for excessive duration; or without adequate monitoring. According to Healthline.com, [MEDICATION(S)] toxicity is another term for a [MEDICATION(S)] overdose. It occurs when you take too much [MEDICATION(S)] .A safe blood level of [MEDICATION(S)] is 0.6 and 1.2 milliequivalents per liter (mEq/L). [MEDICATION(S)] toxicity can happen when this level reaches 1.5 mEq/L or higher. Severe [MEDICATION(S)] toxicity happens at a level of 2.0 mEq/L and above .Symptoms of mild to moderate [MEDICATION(S)] toxicity include: Fatigue tremors uncontrollable movements muscle weakness drowsiness weakness . Serum levels of [MEDICATION(S)] above 2.0 mEq/L can cause severe toxicity and additional symptoms, including: heightened reflexes seizures agitation slurred speech kidney failure rapid heartbeat hyperthermia uncontrollable eye movements low blood pressure confusion coma [CONDITION(S)] death Review of a facility reported incident received by the Rhode Island Department of Health (RIDOH) on 5/17/2022 states in part, .[Patient] .admitted to ICU .on 4/25/22 from .hospital .on [MEDICATION(S)] prior to admission per the COC [continuity of care form; form that summarizes patient information and helps providers communicate clinical information during transitions of care] .from .[hospital] [patient] [to] receive [MEDICATION(S)] 300mg controlled release every other day, admitting nurse .put in order on 4/25/22 to admin [MEDICATION(S)] 300mg ER [extended release] [daily] at bedtime .on 5/15/22 [patient] presente [with] lethargy stat [urgent] labs ordered and reviewed by on call clinician, and again by [Nurse Practitioner] .in [morning] on 5/16/22 .[MEDICATION(S)] level elevated @ [2.03] [mEq/L] BUN @48 [blood urea nitrogen, normal range is 6 to 24 mg/dL, mg per deciliter] son .reccommended [sic] pt. be sent out to .[emergency department] for [evaluation and/or treatment] . Review of a community reported complaint received by RIDOH on 5/18/2022 states in part, My complaint is submitted below in its specific elements and in order of severity; 1.) [Resident ID #108] was administered [his/her] [MEDICATION(S)] medication of 300 mg every day instead of every other day as directed in [his/her] medication information starting on 4/25/22. This was discovered on 5/16/22 after I visited [resident] on 5/15/22 and found [him/her] in a drastically altered state and unable to speak and properly control [his/her] arm movements while attempting to drink from a cup. [S/he] could barely get [his/her] hand to [his/her] mouth to eat .At 11:00 am I requested the [Doctor] on staff and advised him that something was way out of line as [the resident] was not exhibiting these difficulties only a week earlier. The [Doctor] examined [the resident] and confirmed the involuntary motions and the inability of [him/her] to speak properly. The [Doctor] advised he would order blood work to be done. I was concerned about medicine .The current result of this unacceptable oversight is my .[parent] is in the .Hospital and being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . I ordered [him/her] to the emergency roiagnom on the night of 5/16/22 after a family decision was made to no longer allow the [facility] to continue [his/her] care .It was my action on 5/15/22 that lead to the discovery of the unacceptable administration of my [parent's] medication at the [facility] . Record review revealed the resident was admitted to the facility from an acute care hospital in April of 2022 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's continuity of care form from the hospital revealed in part: CONTINUE taking these medications with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Every other night. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medication administration record (MAR) revealed s/he received [MEDICATION(S)] [MEDICATION(S)] ER Tablet Extended Release 300 MG, nightly from 4/26/2022 through 5/15/2022, indicating they received 10 additional doses of this medication. Review of a document titled, Pharmacist Medication Regimen Review indicated a Medication Regimen Review was conducted by Pharmacist, Staff B on 4/28/2022. Additional review of this form indicated that No irregularities were noted. During an interview with Pharmacist, Staff B on 5/17/2022 at 3:55 PM, she revealed that she did not compare the resident's medication orders in the MAR to the orders on the hospital COC form when she completed the resident Medication Regimen Review on 4/28/2022. Review of the resident's progress notes revealed an entry from the Nurse Practitioner, signed on 4/27/2022 at 8:11 AM which indicates to continue [MEDICATION(S)] [MEDICATION(S)] ER 300mg one capsule at bedtime. Review of the resident's progress notes revealed a Physician Narrative H&P (history and physical) by the resident's physician on 4/27/2022 at 7:46 PM which states in part, .[CONDITION(S)] II and Depression: stable at baseline at this time and will continue with the [MEDICATION(S)] . Review of the resident's progress notes revealed a Physician Narrative H&P by the resident's physician on 5/4/2022 at 6:07 PM which states in part, .Reviewed the [facility name] chart including, active Medications, Past Medical History, Social History, Family History and Laboratory results .[CONDITION(S)]: [S/he] is stable at this time at [his/her] baseline without any issues and we will continue to monitor . During an interview with the physician on 5/17/2022 at 12:30 PM he revealed that he did not identify that the [MEDICATION(S)] order was transcribed incorrectly from what was written on the COC form. He acknowledged that the resident received the [MEDICATION(S)] daily instead of every other day. Additionally, he revealed that when he saw the resident on 5/15/2022 s/he was weak and tremulous. During an interview on 5/17/2022 at 12:55 PM with the Nurse Practitioner she revealed that she does look at the COC form and then goes back to verify against the orders at a different time. Stating as an example, that if she forgot to write down the [MEDICATION(S)] dose that she may look at the electronic medical administration record to verify. She further revealed that when she referred to [MEDICATION(S)] daily in her progress note, she probably got that information from the facility's MAR and not the hospital's COC form. Additionally, she was unable to explain why the resident had received 10 extra doses of [MEDICATION(S)]. During an interview on 5/17/2022 at 3:15 PM with Staff Nurse C, she revealed that she was the nurse that completed that admission and entered the orders. She further acknowledged that she could not recall having a second nurse double check the orders. Record review of the resident's laboratory results revealed the following: -4/26/2022 -[MEDICATION(S)] level, 0.44 MMOL/L (millimoles per liter) (reference range 0.50-1.50) -5/15/2022 -[MEDICATION(S)] level, 2.03 MMOL/L. This is a toxic level. Further review of the resident's progress notes revealed the following entry, dated 5/16/2022 time stamped 6:00 PM, states in part, re-reviewed [MEDICATION(S)] med error, elevated [MEDICATION(S)] levels, and patients recent increase in lethargy with .[Nurse Practitioner] .[family member] called and expressed concerns regarding [Nurse Practitioner's] plan [related to] [MEDICATION(S)] level .Spoke with Patients son .again to follow up regarding additional orders/plan of care .patients son not agreeable and states at this time he would like to send patient to [hospital] .patient transported as requested . Review of a progress note dated 5/16/2022 at 7:38 PM revealed the resident was transported to the hospital. During a surveyor interview on 5/17/2022 at 12:04 PM with the Director of Nursing Services and the Administrator they were unable to explain why the resident received [MEDICATION(S)] daily instead of every other day. Additionally, they revealed that the admission nurse failed to have a second nurse double check the orders she entered. They further acknowledged, the error failed to be discovered during the medication reconciliations of the Nurse Practitioner, Physician, or the Pharmacist. This led the resident to receive 10 extra doses of the [MEDICATION(S)].

Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 14 sample residents reviewed for medication administration, Resident ID #108. Findings are as follows: According to Healthline.com, [MEDICATION(S)] toxicity is another term for a [MEDICATION(S)] overdose. It occurs when you take too much [MEDICATION(S)] .A safe blood level of [MEDICATION(S)] is 0.6 and 1.2 milliequivalents per liter (mEq/L). [MEDICATION(S)] toxicity can happen when this level reaches 1.5 mEq/L or higher. Severe [MEDICATION(S)] toxicity happens at a level of 2.0 mEq/L and above .Symptoms of mild to moderate [MEDICATION(S)] toxicity include: Fatigue tremors uncontrollable movements muscle weakness drowsiness weakness . Serum levels of [MEDICATION(S)] above 2.0 mEq/L can cause severe toxicity and additional symptoms, including: heightened reflexes seizures agitation slurred speech kidney failure rapid heartbeat hyperthermia uncontrollable eye movements low blood pressure confusion coma [CONDITION(S)] death Review of a facility reported incident received by the Rhode Island Department of Health (RIDOH) on 5/17/2022 states in part, [Patient] .admitted to ICU .on 4/25/22 from .hospital .on [MEDICATION(S)] prior to admission per the COC [continuity of care form; form that summarizes patient information and helps providers communicate clinical information during transitions of care] .from .[hospital] [patient] [to] receive [MEDICATION(S)] 300mg (milligrams) controlled release every other day, admitting nurse .put in order on 4/25/22 to admin [MEDICATION(S)] 300mg ER [extended release] [daily] at bedtime .on 5/15/22 [patient] presented [with] lethargy stat [urgent] labs ordered and reviewed by on call clinician, and again by [Nurse Practitioner] .in [morning] on 5/16/22 .[MEDICATION(S)] level elevated @ [2.03] [mEq/L] BUN @48 [blood urea nitrogen, normal range is 6 to 24 mg/dL, [mg per deciliter] son .reccommended [sic] pt. be sent out to .[emergency department] for [evaluation and/or treatment] . Review of a community reported complaint received by RIDOH on 5/18/2022 states in part, My complaint is submitted below in its specific elements and in order of severity; 1.) [Resident ID #108] was administered [his/her] [MEDICATION(S)] medication of 300 mg every day instead of every other day as directed in [his/her] medication information starting on 4/25/22. This was discovered on 5/16/22 after I visited [resident] on 5/15/22 and found [him/her] in a drastically altered state and unable to speak and properly control [his/her] arm movements while attempting to drink from a cup. [S/he] could barely get [his/her] hand to [his/her] mouth to eat .At 11:00 am I requested the [Doctor] on staff and advised him that something was way out of line as [the resident] was not exhibiting these difficulties only a week earlier. The [Doctor] examined [the resident] and confirmed the involuntary motions and the inability of [him/her] to speak properly. The [Doctor] advised he would order blood work to be done. I was concerned about medicine .The current result of this unacceptable oversight is my .[parent] is in the .Hospital and being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . I ordered [him/her] to the emergency roiagnom on the night of 5/16/22 after a family decision was made to no longer allow the [facility] to continue [his/her] care .It was my action on 5/15/22 that lead to the discovery of the unacceptable administration of my [parent's] medication at the [facility] . Resident ID #108 was admitted to the facility from an acute in-patient hospital in April of 2022, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital COC revealed a medication list which reads CONTINUE taking these medications with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Every other night. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes revealed the following entry, dated 5/16/2022 time stamped 6:00 PM, states in part, re-reviewed [MEDICATION(S)] med error, elevated [MEDICATION(S)] levels, and patients recent increase in lethargy with .[Nurse Practitioner] .son called and expressed concerns regarding [Nurse Practitioner's] plan [related to] [MEDICATION(S)] level .Spoke with Patients son .again to follow up regarding additional orders/plan of care .patients son not agreeable and states at this time he would like to send patient to [hospital] .patient transported as requested. Record review of the resident's laboratory results revealed the following: - 4/26/2022 -[MEDICATION(S)] level, 0.44 MMOL/L (millimoles per liter) (reference range 0.50-1.50) - 5/15/2022 -[MEDICATION(S)] level, 2.03 MMOL/L. This is a toxic level. During a surveyor interview on 5/17/2022 at 12:30 PM with the physician, he acknowledged that the resident received the medication nightly as opposed to every other day. Additionally, he revealed that when he saw the resident on 5/15/2022 s/he was weak and tremulous. During a surveyor interview on 5/17/2022 at 12:55 PM with the Nurse Practitioner, she acknowledged that the [MEDICATION(S)] order was not transcribed correctly from the COC form causing the resident to receive the [MEDICATION(S)] nightly instead of every other day. She further revealed that when she saw the resident s/he was off and less talkative. Additionally, after she was notified of the medication error, she felt as if s/he could be managed at the facility by holding the [MEDICATION(S)] and administering IV fluids, but the resident's family member wanted her/him sent to the hospital. During a surveyor interview on 5/19/2022 at 10:28 AM with the Rehabilitation Director, she revealed staff had commented on how his/her status had declined, s/he had increased difficulty during treatment with poor carry over. She further revealed that the resident was difficult to engage from the start but did become increasingly difficult to engage. During a surveyor interview with the Director of Nursing Services and the Administrator on 5/17/2022 at 12:04 PM they acknowledged the resident's order to receive [MEDICATION(S)] 300 mg every other night was transcribed incorrectly, resulting in the administration of 10 extra doses of this medication. Additionally, they acknowledged this significant medication error resulted in the resident becoming lethargic and having a toxic [MEDICATION(S)] level of 2.03 on 5/15/2022.